How should an ophthalmologist tell if a child’s development is normal?

Chapter 122 How should an ophthalmologist tell if a child’s development is normal?

Many eye conditions are associated with developmental disorders. Therefore, the ophthalmologist needs to recognize when to make a referral for an opinion about a child’s development.

While a pediatric ophthalmologist is not expected to be as expert in general history taking and examination as a pediatrician, it is essential that he/she understands the rudiments of examining children from a general developmental perspective. It is also important that the ophthalmologist is familiar and confident handling children of all ages. The confidence of parents is greatly enhanced by an ophthalmologist who is confident handling babies and children.

A close collaborative working relationship between the pediatric ophthalmologist and the pediatrician will be essential when there are developmental concerns.

Concerns may arise about children both with normal vision and with severe visual impairment. Children with visual impairment may develop more slowly than their sighted peers. Their progress should be judged against developmental norms appropriate to their level of visual impairment.

The first step is to take a careful history. Remember that parents are usually the best observers of their child’s development and their concerns should be taken seriously.

Risk factors

Some common risk factors associated with developmental problems should be enquired about. These include:

Pregnancy factors: infection (especially cytomegalovirus, toxoplasmosis, and rubella), consumption of drugs or alcohol, smoking, hypertension, and exposure to irradiation.

Health of the fetus: poor growth, reduced fetal movements, or reduced or excessive amniotic fluid.

Delivery: the need for resuscitation and signs of significant encephalopathy in the infant, such as significant drowsiness, poor feeding, and seizures soon after birth suggest that damage was sustained around the time of birth. If no such signs are present, the birth is unlikely to have a causal relationship to later developmental problems. A difficult delivery accounts for few subsequent neurological and developmental problems, although parents often worry about difficulties that they experienced.1

Premature birth (<37 weeks’ gestation): gestational age is strongly correlated with the risk of subsequent developmental problems. When considering whether a premature child is reaching developmental milestones it is appropriate to take account of gestational age up to the age of 2 years.

Serious infection of the central nervous system: meningitis or encephalitis especially in the early weeks or months of life.

Jaundice in the first days of life: prolonged and severe jaundice (>340 µmol/liter).

Conditions of the eye that are known to be associated with developmental problems.

As there are a number of conditions that affect both vision and hearing, always enquire about hearing concerns. Delay in speech development should always lead to referral for assessment of hearing.

Developmental milestones in the fully sighted child

Next, consider whether a child is reaching their expected developmental milestones.

Some key milestones are described in Table 122.1. These are based on normative data from Sheridan,2 Egan,3 and the revised Denver developmental screening test.4 This table shows the average age at which the majority of children achieve particular milestones.

Parents will usually remember the age their child reached major developmental milestones − independent sitting and walking, the development of first words, and when their child was speaking clearly.5

Development is generally considered under the following domains:

Remember, however, these areas are fundamentally connected and progress or deficit in one area is likely to have an impact on another.

When should delay in milestones cause concern?

Box 122.1 provides a list of potential developmental warning signs that will help the clinician to recognize when to be concerned about delay in a particular milestone and therefore request further assessment.

Box 122.1

Developmental warning signs

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Jun 4, 2016 | Posted by in OPHTHALMOLOGY | Comments Off on How should an ophthalmologist tell if a child’s development is normal?

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At any age Excessive hypotonia (floppiness) or hypertonia (stiffness)
Marked asymmetry of posture, movements, or muscle tone
Persistent hand fisting
Persistent tremor, clonus, jerky movements
Tendency to push head back and arch body
Parental concern about hearing or vision
0−3 months Feeding problems – weak suck
4 weeks Not fixing on mother’s face
No response to sound
3 months Not smiling responsively
Not fixing and following
Inability to hold toy placed in hand
4 months